Basic Information
| Provider Information | |||||||||
| NPI: | 1558093997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORUBSKY | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18700 ANITA CT | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530454229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627651012 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2448 S 102ND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532272141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143273000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2022 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041S0200X | N | Behavioral Health & Social Service Providers | Social Worker | School | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.